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Fibrous Adhesive Entrapment of Lumbosacral Nerve Roots As a Cause of Sciatica

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Fibrous Adhesive Entrapment of Lumbosacral Nerve Roots As a Cause of Sciatica Spinal Cord 2001) 39, 269 ± 273 ã 2001 International Medical Society of Paraplegia All rights reserved 1362 ± 4393/01 $15.00 www.nature.com/sc Original Article Fibrous adhesive entrapment of lumbosacral nerve roots as a cause of sciatica K Ido*,1 and H Urushidani1 1Department of Orthopaedic Surgery, Kurashiki Central Hospital, Okayama, Japan Study design: Report of seven patients with ®brous adhesive entrapment of lumbosacral nerve roots as a cause of sciatica, whose radiographic ®ndings were negative and who experienced relief from sciatica immediately after the entrapment was released. Objectives: To describe a new clinical entity of ®brous adhesive entrapment of lumbosacral nerve roots with negative radiographic ®ndings. Setting: Orthopaedic department, Japan. Methods: Clinical evaluation and post-operative outcome in seven patients with entrapment of lumbosacral nerve roots because of ®brous adhesion con®rmed intraoperatively. Results: Radiographic examinations by magnetic resonance imaging &MRI), myelography, and computed tomographic &CT) myelography demonstrated neither disc herniations nor spinal stenosis in all seven patients, and dierential nerve root block was eective for relieving sciatica and low back pain.We con®rmed, intraoperatively, entrapment of the nerve root by ®brous adhesion, and all seven patients were relieved from sciatica and low back pain postoperatively. Conclusion: This study presented seven patients with sciatica caused by ®brous adhesive entrapment of lumbosacral nerve roots who underwent decompression and release of ®brous adhesion.Radiographic examinations, such as MRI, myelography and CT myelography, showed no compressive shadows and also dierential nerve root block was eective for its diagnosis.This study seems to be the ®rst report of patients with entrapment of lumbosacral nerve roots caused by ®brous adhesion, whose radiographic ®ndings were negative. Spinal Cord &2001) 39, 269 ± 273 Keywords: entrapment; lumbosacral spine; nerve root; ®brous adhesion; low back pain; surgery; MRI; myelography Introduction Compression of lumbosacral nerve roots in association adhesion.The aim of this study was to determine the with intervertebral disc herniation and spinal stenosis eectiveness of dierential nerve root block for the usually causes sciatic pain.1,2 Radiographic examina- diagnosis and to emphasize the necessity of surgical tions, such as magnetic resonance imaging &MRI), decompression and release of ®brous adhesive entrap- myelography, and computed tomographic &CT) myelo- ment of the lumbosacral nerve roots. graphy, usually reveal ®ndings of compression in patients with disc herniations and/or spinal stenosis. Methods However, we sometimes encounter patients with sciatic pain whose radiographic examinations reveal neither In our unit, between 1985 and 1998, 1841 patients with lumbar disc herniations nor spinal stenosis. sciatica and low back pain required surgical interven- In this study, we describe the surgical management tion.In seven patients, entrapment of lumbosacral of a series of patients with sciatica whose lumbosacral nerve roots because of ®brous adhesion was con®rmed nerve roots were entrapped because of ®brous intraoperatively and decompressive surgery was re- quired.The clinical data of the patients are summar- ized in Table 1.They comprised four women and three men, their average age at the time of operation was 43 *Correspondence: K Ido, Department of Orthopaedic Surgery, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki-city, Okayama, years, and the average follow-up period was 7 years 710-8602 Japan and 2 months. Fibrous entrapment of nerve root K Ido and H Urushidani 270 Table 1 The summary of clinical data Interval from Low Aected Root Follow- onset to back nerve block Myelo- JOA score Case Age Sex up Cause surgery pain SLR root no. Outcome graphy CTM MRI Pre Post 1 20 M 14Y8Mo Sports 5Mo (+) 108 (+) left S1 1 eective n.p. n.p. n.p. 10 24 2 50 F 8Y11Mo (7) 4Mo (+) 458 (+) left L5 1 eective n.p. n.p. n.p. 12 24 3 39 F 8Y (7) 7Mo (+) (7) right L6 1 eective n.p. n.p. n.p. 16 24 4 44 F 7Y11Mo (7) 4Mo (+) 508 (+) right L5 1 eective n.p. n.p. n.p. 14 22 5 58 M 5Y9Mo (7) 1Y (+) 708 (+) right L5 2 eective n.p. n.p. n.p. 8 19 6 43 M 2Y11Mo Labor 1Y1Mo (+) (7) left L5 1 eective irregular n.p. n.p. 12 18 7 50 F 2Y (7) 5Mo (+) 408 (+) left L5 2 eective n.p. n.p. n.p. 15 27 M: male; F: female; Y: year; Mo: month; SLR: straight leg raising Radiographic examinations one patient, however, slightly irregular shadow of the Initially, MRI was performed for all patients. Patients nerve root was observed. All the seven patients with negative ®ndings on MRI underwent myelography complained of sciatica accompanied by low back pain. and CT myelography in order to look for slight Five of the patients had no cause for the development compressive shadows caused by intervertebral disc of the symptoms. Two patients had a suggestive life- herniations which could not be detected by MRI, style history: a football player and a manual laborer. myelography and CT myelography. Dierential nerve None of the seven patients experienced previous root block using lidocaine was attempted at suspicious medical history of low back pain and sciatica. The levels of neurological symptoms to identify which nerve average interval between onset of the symptoms and root was aected and also to con®rm whether or not surgical intervention was 7 months, and seemed not to pain relief was obtained. In the patients without be dierent from that of lumbar disc herniations or remarkable ®ndings in MRI, myelography and CT spinal stenosis. The average age at the time of surgery myelography, the level of this nerve root block was was close to that of lumbar disc herniations, and was determined according to physical examination data, somewhat younger than spinal stenotic patients. such as pain, sensory de®cit, and motor weakness. Dierential nerve root block at suspicious sympto- matic levels was eective for relieving both sciatic pain and low back pain in all seven patients. Intraopera- Surgery tively, we con®rmed entrapment of the nerve root by After exploring the spinous process and lamina, ®brous adhesion. All the seven patients experienced laminotomy was performed using an osteotome complete relief from sciatic pain and low back pain followed by unroo®ng of the symptomatic nerve root. immediately after we released the ®brous adhesion, and As neither disc bulging nor compression of the nerve the JOA scores improved in all seven patients soon after root and the dura because of spinal stenosis was the operation. During an average follow-up period of 7 observed, discectomy was not performed. Entrapment years and 2 months, no recurrence of sciatic pain of the nerve root by ®brous adhesion was con®rmed accompanied by low back pain was observed and the and exfoliated. Microsurgical manipulation was often JOA scores were unchanged. useful for precise observation. These procedures resulted in release of the nerve root and creation of space around it. Representative case presentation Case 7: A 51-year-old woman with low back pain Clinical evaluation and left sciatica was admitted to our hospital. Physical Preoperative clinical symptoms and those soon after examination on admission demonstrated positive the operation were assessed using the criteria for the straight leg raising at 458 in the left side and JOA evaluation of low back pain treatment outcome score was 15 points. Dierential nerve root block using proposed by the Japanese Orthopaedic Association lidocaine at left L5 nerve root level was eective in (JOA) (maximum score: 29 points) which is commonly relieving both the leg pain and low back pain (Figure used in Japan (Table 2). 1). MRI and CT myelography showed no disc bulging at L4/5, and myelography demonstrated no abnormal Results shadow of left L5 nerve root (Figures 2 ± 4). After completing laminotomy at L4/5, ®brous adhesive Radiographic examinations by MRI, myelography and entrapment was observed. Careful detachment of CT myelography demonstrated neither disc herniations ®brous adhesion resulted in setting the nerve root free nor compression of the nerve root and the dura because and the patient was relieved from both sciatic pain and of spinal canal stenosis in any of the seven patients. In low back pain and JOA score increased to 27 points. Spinal Cord Fibrous entrapment of nerve root K Ido and H Urushidani 271 Table 2 The criteria for the evaluation of low back pain treatment outcome proposed by the Japanese Orthopaedic Association (JOA) I. Subjective symptoms (9 points) A. Low back pain a. none 3 b. occasional mild pain 2 c. frequent mild or occasional severe pain 1 d. frequent or continuous severe pain 0 B. Leg pain and/or tingling a. none 3 b. occasional mild sypmtoms 2 c. frequent mild or occasional severe 1 symptoms d. frequent or continous severe pain 0 C. Gait a. normal 3 b. able to walk farther than 500 m, even 2 though it results in pain, tingling, and/or muscle weakness c. unable to walk farther than 500 m, 1 because of leg pain, tingling, and/or muscle weakness d. unable to walk farther than 100 m, 0 because of leg pain, tingling, and/or muscle weakness II. Clinical signs (6 points) A. Straight leg raising test (including tight hamstrings) Figure 1 Dierential nerve root block using lidocaine of left a. normal 2 L5 nerve root was completely eective b308*708 1 c. less than 308 0 B. Sensory disturbances a. none 2 Discussion b. slight disturbances 1 The nerve roots in the lumbosacral region may be easily c. marked disturbances 0 compressed by intervertebral disc herniations and/or C. Motor disturbances spinal stenosis. Such mechanical compressions of the a. normal (grade 5) 2 nerve root may induce functional changes, such as b.
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